NHS Improvement’s most senior nurse has said she will intervene to back directors of nursing where they are feeling pressured to make bad decisions about staffing.
Dr Ruth May, the regulator’s executive chief nurse, also insisted forthcoming guidance on safe staffing from her organisation would be based on the latest evidence and research.
“Sometimes that will mean me intervening to support the director of nursing”
NHS Improvement’s first three staffing guidance documents would be published for consultation next month, she told Nursing Times’ sister title Health Service Journal.
The three areas covered will be inpatient, mental health and learning disability services, she said. Work on the remaining settings – emergency, maternity, community and children’s services – will be published for consultation early next year, and all the guidance will be finalised by early summer.
Dr May said fellow regulator the Care Quality Commission would sign off on the guidance – to be described as “resource guides” – and would inspect trusts against it.
“It is incumbent on the trust to have quite clear systems and processes to determine what is safe and effective and sustainable staffing,” she said. “That is very clear in the expectations…”
“It’s right that I keep making sure directors of nursing are able to make decisions based on the evidence in front of them, and I will work to support them to do that and sometimes that will mean me intervening to support the director of nursing in a much more proactive way. I will definitely be prepared to do that,” she stated.
“We are not going to ignore any evidence. Time has moved on since Francis did his report”
NHS Improvement took over the role of developing guidance on safe staffing levels last year, after the Department of Health suspended work being done by the National Institute for Health and Care Excellence.
The previous NICE work was started in response to a recommendation in the Francis report. After the NICE work was controversially cancelled some expressed concerns that NHS Improvement’s guidance would not be properly based on evidence about staffing.
Dr May said the new regulator had ensured there were relevant experts on each of its committees that are overseeing the work, and they had been commissioned to carry out evidence reviews.
“We are not going to ignore any evidence. Time has moved on since Francis did his report,” she said.
“More evidence is available to us and we must make sure we use that evidence in our considerations,” she said. “I genuinely believe this will be an evidence based process, we have got the academics in there with us and they certainly tell us their views.”
NHS Improvement’s guidance is expected to discuss staff groups beyond registered nurses, though its exact extent is not yet known.
“No decision has yet been made about where nurse associates will sit”
Dr May declined to say whether the new guidance would include minimum staffing ratios, as was recommended by NICE in leaked draft guidance for emergency departments, but noted that their inclusion had not been barred.
“It will either land well with directors of nursing and frontline staff alike or not,” she said. “It is important to measure inputs but not inputs alone. I believe if you measure inputs and outcomes you will get the right skill mix and numbers of staff that you require,” she said.
NHS Improvement also said the evidence reviews commissioned by the committees would be published alongside the new guides along with measurement tools.
In an interview with Nursing Times last month, Dr May also said trusts with the best and worst nurse retention rates were to be targeted in a new programme to tackle staffing problems. The scheme will see nursing directors share effective strategies that have helped them hold onto staff and reduced turnover.
Meanwhile, the regulator has not yet decided how to count nursing associates as part of a proposed high-profile staffing efficiency metric.
NHS Improvement is currently developing a controversial indicator, called “care hours per patient day”, which was recommended in the Carter review of NHS efficiency.
It has been confirmed that the measurement tool, which is expected to be adopted across the NHS, will split care provided by registered nurses from un-registered healthcare assistants.
However, since the introduction of the tool was announced, plans for the new nursing associate role have also been revealed.
The new role is being developed by Health Education England to act as a “bridge” between healthcare assistants and nurses, with 2,000 people due to begin training for it in January.
Senior nurses appointed by national regulator
Nursing unions have raised concern that quality could be compromised if the new staff are used as substitutes for registered nurses, though ministers have argued that they will be used in this way.
Dr May said: “I imagine that [associates will be counted separately from registered nurses] but I am not going to pre-judge it”.
Mark Radford, NHS Improvement’s recently-appointed director of nursing improvement, added: “No decision has yet been made about where nurse associates will sit.”
Asked about the nursing associate role in general, Dr May: “I do support the introduction of the role. They have the potential to add value to our whole clinical workforce.
“But I also want to make sure it is recognised that registered nurses are the backbone to what clinical care is being given,” she said. “I accept though, because of the introduction of the nursing associates, there is some work we need to do around the clarity of the registered nurse in some of those settings.”
Confirming a view made earlier in a statement with other NHS nurse leaders, she added: “I feel passionately these new nurse associates need to be regulated, without any doubt.”
Documents leaked last month showed HEE was expecting nurse associates to be able to work independently of nurses and be capable of calculating and administering controlled drugs, a role usually reserved for qualified nurses.
- Nursing associates will be able to give drugs unsupervised
- Leaked document reinforces call to regulate new role
- Nursing associate role created too quickly, warn leaders
Studies have already demonstrated the dangers of trusts attempting to use nursing associates as substitutes for registered staff.
Research across 137 acute trusts between 2009 and 2011 found trusts that employed more HCAs per bed had an increased risk of mortality.
In addition, a large European study published last night found that diluting nursing skill mix in hospitals was also linked to an increased risk of patients dying.
The study found that for every 25 patients, replacing just one nurse with an HCA was associated with a 21% increase in the odds of dying compared with average nurse staffing levels and skill mix.
New drive on pressure ulcers
NHS Improvement has launched a new drive to help reduce the number of avoidable pressure ulcers across the NHS.
The regulator was expected to publish a new resource for trusts earlier this week to help standardise reporting of pressure ulcers, with advice on making improvements and sharing best practice.
The 15 best performing organisations from around the country will partner with the worst performers to try and accelerate improvements, with a new national advisory board led by Cathy Winfield, chief nurse at Derby Teaching Hospitals NHS Foundation Trust.
Mark Radford, former chief nurse at University Hospitals Coventry and Warwickshire, who has recently joined the regulator as its director for nursing improvement, said the new drive was to help trusts better “measure and improve” care to prevent and manage pressure ulcers.
He said NHS Improvement would look to standardise approaches for reporting, reviewing the evidence and carrying out root cause analysis investigations.
“We are going to take the top 15 organisations that deliver substantial improvements around pressure ulcers and align them with those that have been more challenged with a strong focus on community and hospice sectors. We are looking a lot at pathways and how people transition between care settings,” he said.
Dr Ruth May, NHS Improvement’s executive chief nurse, added: “People have done extremely well to reduce pressure ulcers but we need to do to make sure we are taking the next step forward and widen it across other sectors and across the whole of England.”